Job Summary
The Care Manager/Community Health Worker (CHW) supports the development of patient-centered, team-based care. S/he will support Shannon as a health care system (clinic and hospital departments as needed). Care Manager/CHW(s) are expected to help team members ensure patients are receiving support and resources within the community & reduce client barriers to health care and needed community resources and services. Facilitate communication and coordination between community resources/services, community partners, and healthcare providers. Maintain knowledge and understanding of available community resources, services, and programs. A few examples include the following: social determinates of health, educating patients on topics related to chronic disease prevention, suicide prevention, end of life planning, physical activity/nutrition. Care Manager/Community Health Worker (CHW) are also involved in shared savings programs by identifying opportunities to reduce healthcare costs while maintaining or improving the quality of care. This includes working with patients to manage chronic conditions, prevent unnecessary hospitalizations, and ensure they access cost-effective community resources.
Supervises the Following Positions
Positions: N/A
Physical Requirements
- The ability to perform the duties and responsibility of the position, with or without reasonable accommodations for disabilities.
- The ability to consistently lift, push or pull loads of up to fifty (50) pounds. (Unless nursing 50)
- Sufficient strength, mobility and stamina to make frequent location and position changes, assist with patient care, and perform other physical activities of average difficulty.
- Candidates whose disabilities make them unable to meet the requirements will still be considered fully qualified if they can perform the essential functions of the job with reasonable accommodations.
- May be exposed to infectious or contagious disease.
- May have to handle emergency situations.
- May be subject to irregular hours.
- May be required to wear protective equipment such as eye protection, face protection, masks, sterile/nonsterile gloves, isolation gowns.
- May be exposed to toxic/caustic/chemicals/detergents.
- Physical activities include continuous sitting, and occasional walking, standing, bending, squatting, climbing, kneeling and twisting.
- Activity Conditions (Occasionally, Frequently, Continuously):
- Sitting- Continuously
- Walking- Frequently
- Standing- Occasionally
- Bending-Occasionally
- Squatting- Occasionally
- Climbing-Occasionally
- Kneeling-Occasionally
- Twisting-Occasionally
Visual and Hearing Requirements
- Must be able to see with corrective eye wear.
- Must be able to hear clearly with assistance
Working Conditions
Primarily Works in a well-lighted and air-conditioned environment with period of heavy workload and stress. Works in various conditions.
Performance: Essential Functions
Decision Making: Ability to make decisions and takes appropriate action based on the information they have. Recognizes own limitations and consults with the supervisor, manager, or team member when appropriate.
Time Management: Works efficiently and manages duties to ensure that tasks are completed with accuracy and within the scheduled shift or reasonable amount of time.
Quality & Quantity: Demonstrates accurate, knowledge and skill to carry out job duties. Follows departmental work policies and procedures. Speed and consistency of output and time utilization of job duties.
Computer Knowledge & Electronic Equipment Use: Demonstrates ability to consistently utilize electronic equipment and online computer programs to perform job duties, including electronic documentation, and order entry.
Resource Utilization: Consistently utilizes and maintains supplies and equipment to minimize lost charges and unnecessary equipment repair-replacement.
Confidentiality: Adheres to established policies on privacy and security requirements for compliance with the Health Insurance Portability and Accountability Act (HIPAA), as applicable by Shannon Policy.
Performance: Position Specific Essential Functions
- Develops a keen understanding of primary care practice requirements for optimal, coordinated population health.
- Works as an effective team member of the population health management program.
- Manages data collection, prepares reports on findings, and provides interpretations and recommendations.
- Contributes to quality improvement and care redesign of population health efforts.
- Proactively help manage target populations and increase preventative health screenings.
- Provide data management, coordination, and patient outreach as needed for specific target patient populations.
- Medicare Shared Savings data analytics, medication adherence, tracking preventive health metrics.
- Proficient in Medical Terminology
- Contributes to a positive experience for patients and families through courteous telephone interactions and interview activities, accurate and expeditious routing, as well as referral to appropriate clinical staff when necessary.
- Respond to inquiries from the practice regarding outcomes of outreach calls to patients. Synthesize, sort, format data, and generate ad-hoc reports. Presentation of data may be required at times.
- Assist in process mapping and development of workflows for population health management at each of the designated primary practices. Answer and/or research questions on problems the clinicians have identified.
- Recognize and report data inconsistencies to appropriate personnel.
- Contributes to the teamwork within and between departments.
- Regularly attends and participates in meetings with coworkers and practice staff.
- Provides constructive ideas, suggestions, and feedback in a positive manner.
- Works collaboratively with co-workers to effectively resolve issues that impact departmental or hospital operations.
- Perform all job functions in compliance with applicable federal, state, local and company policies and procedures.
- Collaborate with care teams to establish population-appropriate, pre-visit, and point of care processes. Provide data to the care teams to properly perform these processes.
- Monitor and correct patient attribution to the practice and the care teams within the practice.
- Experience in promoting healthcare behavior change is desirable.
- Proficient in data management and reporting.
- Proven problem-solver with ability to multi-task.
- Prior use of electronic health records and other health care information systems desirable.
- Performs other duties as assigned.
Qualifications
Education
- Required
- High School Diploma, GED, or equivalent
Experience:
- Preferred
- Two years of experience in Customer Service in a Health-related field
Certification/Licensure:
- Required
- Valid Texas Driver’s License
- Basic Life Support (BLS) Certification
- Must obtain within ninety (90) days of start date
- Preferred
- Community Health Worker Certification
- Certification in Medical Assisting
